Bipolar Continuing Education CEU

Family Psychoeducation
Workbook
Chapter 10: Other Clinical Models for Psychoeducational Multifamily Groups
Introduction

As the effectiveness of the Family Psychoeducation approaches to the treatment of schizophrenia has become established, interest has developed in extending these models to other conditions. That has led to the development of several newer approaches designed for consumers with specific diagnoses or for specific situations, such as when a given consumer has no family available or family involvement is complicated by a history of trauma within the family. The design of these newer models has proceeded with the same method as was done in working with people who experience schizophrenia: specific aspects have been designed to ameliorate phenomena that have been shown to influence outcome in previous research. That is, they are rooted in empirical findings, rather than theory, and those findings range over the entire body of psychiatric and psychological research, including both biological and psychosocial studies. Though they do not have the depth of outcome study results that has been shown for the models for people who experience schizophrenia, evidence is accumulating that they are just as effective. The practitioner who sets out to apply these models should review the available literature, since at the time of this writing many of these models were being tested, but results were not yet published.

Included here are brief summaries of descriptions of psychoeducational multifamily group treatment approaches for people with several common diagnoses as well as a model for ameliorating the effects of chronic medical illness on the family. The practitioner interested in applying these newer methods should consult the volumes in which they are described fully and seek training from qualified trainers.

Multifamily Groups for Bipolar Illness

David A. Moltz, M.D.
Margaret Newmark, M.S.W.

The psychoeducational multifamily group model must be significantly modified for people who experience a bipolar disorder. The symptoms, course and family responses have been shown to be different than in schizophrenia, and recent biological research has highlighted major differences in brain function between the disorders. A key finding is that family “expressed emotion” (defined earlier in text as behaviors perceived by the consumer as being critical and/or lacking warmth/support) affects relapse, but there is an even greater biological contribution to relapse than in schizophrenia. For instance, Miklowitz and his colleagues found that family psychoeducation, in the form of single-family behavioral management, reduced relapses markedly, but from nearly 90% to about 50%, as opposed to the 40% to 15% reduction observed for consumers with schizophrenia. Thus, biological and psychosocial factors seem to be more evenly weighted in determining course of illness in bipolar disorder; nevertheless, family psychoeducation remains a powerful treatment in preventing relapse and improving longer-term outcomes.

A Model for Bipolar Disorder

This model, developed by Moltz, Newmark, McFarlane and associates, was first implemented at a public mental health center in the South Bronx of New York City and later at a community mental health center in coastal Maine. It has been effective in both settings. Only one other group has published a report of psychoeducational multifamily group approach. Anderson and associates compared a family process multifamily group to a psychoeducational multifamily group for short-term treatment of hospitalized consumers with affective disorders. One of the few significant differences between the groups was that those attending the psychoeducational group reported greater satisfaction than those attending the process group. Therefore, whether or not the psychoeducational format had measurable clinical advantages, it was more valued by family members. For further information please refer to the references in Chapter 12.

The key elements of this model are the same as in the approach for consumers with schizophrenia. Each is modified in important ways to match the clinical and psychosocial problems encountered in bipolar disorder.

The materials cited in Chapter 12 contain information regarding the use of single family groups for individuals with bipolar disorder.

Joining

Initial joining sessions are held separately for the consumer and the family.
Individual and family sessions have similar structure, since the individual with bipolar illness is usually able to participate fully.
Meetings with the consumer and the other family members are often carried out separately during the acute phase of illness, but usually together if joining occurs after the manic phase is over and family meetings with the consumer are less likely to be emotionally intense.
Content

The content of the joining sessions is modified to reflect the specific impact of bipolar illness on the family. It includes:

Extensive discussion of the history of symptoms and course of illness
Identifying precipitants and prodromal signs
Emphasis on differing attitudes and attributions
Discussion of inter-episode functioning, that is to say, “how is life between episodes?”
Conjoint sessions

After several sessions with the family and the consumer meeting separately, they are seen together for one or more conjoint sessions facilitated by the two practitioners who will be co-facilitating the group. These conjoint sessions allow the family to come together as a unit prior to the multifamily group, while the separate sessions allow each party to express their concerns without constraints and thereby diminishes conflict during the joinings.

Educational workshop

The structure and format of the bipolar workshop are similar to the schizophrenia workshop except that the consumer is included. Content is determined by the specific characteristics of the illness and includes:

Symptoms of manic and depressed episodes, differences from normal highs and lows
The issue of will-power
The question of the “real” personality
The impact of acute episodes on the family
The long term impact of the illness on the family
Theories of etiology of the illness
Short and long-term treatment strategies
Ongoing group meetings

The structure of the multifamily group meetings is essentially the same as the schizophrenia model.

Challenges to group formation and maintenance

Several issues related to specific characteristics of bipolar illness have presented challenges to group formation and process:

Diagnostic ambiguity
Maintaining the group structure
Co-occurring conditions, especially substance abuse in consumer and other family members.
Outcomes

In general, consumers reported that:

they were less angry over time;
they had less debilitating episodes when they did occur;
they were better able to manage symptoms and episodes;
they experienced fewer hospitalizations; and
they were more able to appreciate their family’s experience.
Family members reported:

increased confidence in their ability to cope with the illness;
increased confidence in the consumer’s ability to manage the illness; and
benefits from the program even if the consumer did not attend.
Practitioners reported:

it took about two years to master the techniques;
they learned to see their role more as consultant than therapist;
they better appreciated family’s and consumer’s experience of illness and efforts to cope with it; and
each person’s struggle with illness is different.
Multifamily Group Treatment For Major Depressive Disorder

Gabor Keitner, M.D. Ivan W. Miller, Ph.D.
Laura M. Drury, M.S.W. William H. Norman, Ph.D.
Christine E. Ryan, Ph.D. David A. Solomon, M.D.

To date, the only previous multifamily group treatment for consumers who experience depression has been the model developed by Anderson (1986). This multifamily approach has been used at the University of Pittsburgh for many years, however the only empirical data collected on this model is a comparison of participants’ satisfaction with the group. This study indicated that consumers and families were very satisfied with the treatment and believed that they obtained significant benefits. However, despite the fact that this intervention has been incorporated into several long-term studies of depression, there has been no study of the potential effects of this multifamily treatment on outcome or course of illness in major depression. Such studies are underway now and preliminary results are promising.

Conducting multifamily group treatment for people with depression

Consumers with mood disorders participated in psychoeducational multifamily groups in a 5-year federally-sponsored research study. Consumers with unipolar and bipolar illness were combined in order to ensure a critical mass of consumers and families, and also because we felt that there was a significant overlap in the themes of remission and relapse between unipolar and bipolar forms of mood disorders. In addition, both unipolar and bipolar consumers had a common experience in the depressive phase of the illness and it was assumed that a certain percentage of unipolar consumers may eventually experience an episode of mania.

Much of the following material was drawn from previous descriptions of psychoeducational groups.

Overview of goals and structure

Helping consumers and family members become knowledgeable about the signs and symptoms of depression and mania;
Promoting relationships and increasing understanding of the effects of the illness by sharing information, support and members' perspectives on family interactions;
Consumers and family members gain insights and learn new coping strategies in dealing with different phases of the consumer's illness; and
Consumers and families have a better understanding of how they can work with each other and with mental health professionals to deal with the illness.
Family and group composition

A core feature of this program is that both the consumer and family members attend the sessions. All family members of the household over the age of 12 are expected to attend. A minimum of four families seems to be necessary to insure adequate activity and group discussion. Groups of five to six families, or twelve to fourteen people, are optimal. Groups typically include consumers with both bipolar disorder and others with major depression.

Practitioners

Two co-leaders are needed. The leaders deal with any consumers or family members who become upset during a session. Leaders should be experienced in working with consumers, their families, and also in group process and therapy. They should know about current issues and treatments of major depression and bipolar illness, including the biopsychosocial model of mood disorders.

Clinical procedures

The group leaders (practitioners) should meet before each session to discuss the content of the session and the division of tasks between them. They should also meet immediately after the session to review and assess group members and plan future agendas and strategies. This debriefing is especially important if a crisis occurred during the group session with either a consumer or a family member.

Screening session

This is an individual meeting between the consumer, family member(s) and one of the two co-leaders. It serves to:

Introduce the consumer and family to the therapist;
Provide an opportunity to assess the family's and consumer's knowledge about mood disorders, coping skills and methods of dealing with the illness;
Build an alliance between the therapist consumer, and family; and
Let the therapist assess the appropriateness of the family and the consumer for the psychoeducational group.
Structure of psychoeducation groups

Please refer to the references in Chapter 12 for specific information about the structure of these groups.

Conclusion

The optimal treatment of depression has yet to be defined. Pharmacotherapy, psychotherapy, family therapy, and group therapy all play a role for some consumers at some point in the illness. The multifamily group format is a welcome addition to the currently available treatments for depression. The role of the family is significant in determining the course of the depression and its response to treatments.

Multifamily Psychoeducational Treatment of Borderline Personality Disorder

Cynthia Berkowitz, M.D.
John Gunderson, M.D.

The development of psychoeducational multifamily treatment of borderline personality disorder (BPD) is prompted by four factors:

the need for novel psychosocial interventions in this disorder,
the success of psychoeducational multifamily treatment of schizophrenia,
the need for more effective family interventions in this disorder, and
the emergence of a deficit model of BPD.
Dialectical Behavioral Therapy has been developed by Marsha Linehan and colleagues as a disorder specific treatment of BPD, focusing on the diminution of the self-destructive behavior that is the major cause of morbidity in BPD. It is the only psychosocial treatment of this disorder that has been subjected to a controlled outcome study. Linehan has established the effectiveness of this cognitive-behavioral treatment of BPD.

Practitioners who treat individuals with BPD know that the recurrent crises that mark the course of the illness often occur in response to interactions between the individual with BPD and relatives. This pattern strongly suggests that a treatment targeted at altering the family environment could positively influence the course of the disorder. The findings of Young and Gunderson, (1995) suggest that adolescents with BPD saw themselves as being significantly more alienated than did adolescents with other disorders. Their research found that alienation in the family environment is a useful target for intervention and indicates that psychoeducation may be able to diminish feelings of alienation.

Based on studies of the role of expressed emotion (EE) in BPD by Jill Hooley as well as by John Vuchetich, (the latter study in association with development of the current treatment), we hypothesize that EE in the family may be a risk factor for worsening psychosocial functioning in the individual with BPD.

Rationale for psychoeducational multifamily treatment of BPD

The following principles borrow heavily from the previous work of Anderson, Hogarty, Falloon, Leff and McFarlane in the development of psychoeducational treatment but also incorporate emerging concepts of BPD, particularly the functional deficit model.

BPD is characterized by functional deficits of (i) affect and impulse dyscontrol, (ii) intolerance of aloneness and (iii) dichotomous thinking. If individuals with BPD have functional deficits in their ability to cope, it follows that they would benefit from an environment that could help them cope with those deficits.
The functional deficits above may render individuals with BPD handicapped but not disabled. This means that they can be held accountable for their actions but that change for them occurs very slowly and with great difficulty.
BPD is an enduring disorder characterized by recurrent crises. The specific goal of the treatment is to diminish crises rather than to cure the disorder. We hypothesize that stress in the family environment may significantly influence the course of the disorder.
Families can influence the course of illness in that they can either diminish the stresses that cause relapses or inadvertently create them. Families are asked specifically to make the home environment calmer and to reduce the stress the consumer who experiences BPD is subjected to.
Living with an ill relative has stressful consequences for the family. A major goal of the current treatment is to diminish stress within the family.
Family members will want to use education to change their behavior if they believe they can help an ill family member by doing so.
Stress within the family may have at its root alienation between the individual with BPD and the family. Psychoeducational treatment moves parents away from issues of their possible causal role in the occurrence of the illness and away from blaming and criticizing the individual with BPD.
The role of the multifamily group in treatment of BPD

The mechanisms of the multifamily group directly address the particular problems facing the families of individuals with BPD, including the need for:

improved clarity of communication and directness;
diminished hostility; and
diminished over-involvement.
Structure of psychoeducational multifamily group treatment

The same three-stage structure used in the treatment of people with schizophrenia can be applied to people with borderline personality disorder. In this model, family psycoeducational treatment begins with a joining phase followed by an educational workshop. Families then join a multifamily group for an extended period of biweekly treatment. Again, the details of conducting the joining sessions, educational workshop and multifamily group sessions are described in the references listed in Chapter 12.

Treatment outcome

The psychoeducational multifamily group treatment of BPD is currently under study in a project involving two multifamily groups. Each of the families consisted of a mother or two parents with a daughter having BPD. Data is currently available for only eight of the participating families:

66.7 percent felt that the multifamily group helped them to modulate angry feelings
66.7 percent felt less burdened
All participating families felt that the group improved their communication with their daughters (75 percent felt that the improvement was “very great” )
All participating families felt that the treatment improved their knowledge of the disorder
91.6% of parents felt that the treatment had helped them to set limits
All of the participating families felt supported by the group
Conclusion

While the evidence supporting its effectiveness for people who experience borderline personality disorder is preliminary, the data available suggests that consumers are experiencing improved communication and diminished hostility within their families.

Multifamily Behavioral Treatment of Obsessive Compulsive Disorder

Barbara Van Noppen, M.S.W.
Gail Steketee, Ph.D.

Education about consumers with obsessive compulsive disorder (OCD) and the reduction of critical responses to behavioral symptoms are important family factors in the course of illness and possibly in treatment outcome for OCD. Clinical investigation of family members’ responses to OCD symptoms and of their impact on the symptoms can lead to the development of family behavioral interventions that may help both the consumer and the family. Multifamily behavioral treatment (MFBT) includes consumers and their significant others in a 20-session intervention (12 weekly and 6 monthly sessions) over a period of 9 months. Preliminary findings revealed efficacy of MFBT comparable to standard individual behavioral therapy. Furthermore, reductions in the symptoms experienced by consumers with obsessive compulsive disorder who completed MFBT have been maintained at one-year follow-up.

Multifamily behavioral treatment (MFBT)

MFBT, compared to single-family behavioral therapy, offers the opportunity for reduction in perceived isolation, enriched opportunities for problem solving and emotional distancing, enabling family members to respond in a less personalized way to the symptoms. A sense of community and social support often develops through the course of the MFBT, as families share stories with one another. There is a lessening in feelings of shame and stigma, which encourages family members to take a larger role in treatment and join with the consumer to combat the symptoms of obsessive compulsive disorder. The presence of other families with similar problems provides an opportunity for consumers and families to learn effective negotiation of agreements and to adopt symptom management strategies modeled by other members of the group. Additional potential benefits of multifamily intervention are reduced therapist burnout and greater cost-effectiveness of treatment.

A recent uncontrolled trial by Van Noppen and colleagues examined the effects of MFBT for 19 consumers and family members treated in 4 groups. Consumers experienced significant reductions in obsessive compulsive symptom severity and similar reduction in scores on a measure of family functioning. Among MFBT consumers, 47% made clinically significant improvements (reliably changed and scoring in the non-clinical range on OCD symptoms) at post-test, and 58% achieved this status at 1-year follow-up. Results from MFBT were comparable to those achieved by individual behavior therapy. Overall, the multifamily intervention was quite effective, although some consumers did not show strong gains and there is clearly room for improvement.

Features and procedures of MFBT

MFBT is similar to methods described by McFarlane and Falloon, but uses interventions specifically aimed at reducing obsessive-compulsive symptoms and changing dysfunctional patterns of communication. This family group treatment incorporates psychoeducation, communication and problem-solving skills training, clarifying boundaries, social learning and in vivo rehearsal of new behaviors. There is also in-group observation of exposure and response prevention with therapist and participant modeling.

4-6 families (no more than 16 total participants is recommended), including consumer and others who have daily contact with the consumer. Co-leaders are optimal; at least one leader should have an advanced degree in social work, psychology or certified counseling and experience in clinical work with individuals, families and groups.
Sessions are 2 hours long and typically meet in the late afternoon or early evening.
The key clinical procedures include:

Each consumer and family has a pre-treatment screening by phone with the therapist(s) to determine appropriateness for the group and readiness for treatment; following this, two intake sessions are scheduled;
At the intake sessions, 1 1/2 hours each, pretreatment forms are completed, symptom severity and family response styles determined, goals of the group and behavioral therapy principles are discussed, and pre-treatment concerns and questions are addressed;
Treatment is comprised of 12 weekly sessions and 6 monthly group follow-up sessions, providing:
education about OCD and reading of self-help material;
education about families and OCD;
in vivo exposure and response prevention plus homework and self-monitoring;
homework discussion with family group feedback and problem-solving; and
behavioral contracting among family members and communication skills training.
Conclusion

MFBT appears to be a good alternative to labor-intensive individual behavioral treatment. Recent research findings suggest that MFBT may especially help consumers who experience obsessive compulsive disorder and have not benefited from standard individual treatment and who are living with family members. MFBT incorporates family members into behavioral treatment by teaching family members and consumers to negotiate contracts. The goal of this treatment is to encourage anxiety reduction for the consumer, to educate and model reasonable interactive responses within families, and to remove family members from the consumer’s compulsions in a supportive manner.
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